Protocols for Safe and Infection Free Dialysis Unit for Patients

Introduction:

Patients who undergo dialysis treatment have an increased risk for getting an infection. Hemodialysis patients are at a high risk for infection because the process of hemodialysis requires frequent use of catheters or insertion of needles to access the bloodstream. Hemodialysis patients have weakened immune systems, which increase their risk for infection, and they require frequent hospitalizations and surgery where they might acquire an infection.

The incidence of serious infections among patients receiving maintenance HD remains unacceptably high. Acquisition of infections in HD facilities is often due to suboptimal infection control practices, and 100% utilization of recommended infection control guidelines is essential to prevent infections in this vulnerable population. Prevention efforts may require that HD organizations devote greater resources to ensure implementation of infection control practices. To lead these efforts successfully, medical directors and other nephrologists must understand and champion the CDC infection control practice guidelines. When nephrologists lead by example and collaborate closely with nursing management and staff, we may achieve our target of zero preventable infections and reduce infection-related morbidity and mortality.

The dialysis facility environment may be a source of infection transmission. Inadequately cleaned and disinfected dialysis stations, priming buckets, HD machines, effluent drain wall box, and other equipment have been implicated in transmission of pathogens in HD facilities.

The CDC has specific recommendations and checklists for dialysis station disinfection, which should be performed only after the patient has left the HD unit. Careful use of single-dose and multidose medication vials is also essential in prevention of infection transmission.

Single use should only be accessed once, and whenever possible, multidose vials should be dedicated to one patient. Medications and saline syringes should be prepared in a dedicated, clean, separate area in the dialysis unit and taken to individual stations by hand.

A medication cart should not be used to take medications from station to station, because this has been associated with transmission of infections, especially HCV.

Reuse of dialyzers has been associated with outbreaks of gram-negative bloodstream infections, and reuse facilities must ensure strict adherence to sterilization protocol to mitigate the risk of infection transmission.

Why is infection prevention important for hemodialysis patients?

• Infections (including those affecting the bloodstream) are the second leading cause of death among hemodialysis patients.
• Infections acquired in dialysis units can kill, disable, hospitalize, and/or prolong illness in patients while disrupting lives and increasing the cost of treatment.
• Dialysis-related infections can occur in many body locations including the bloodstream, bones, lungs, and skin.
• There are many reasons why patients receiving dialysis have a high risk of infections, including the close distance of patients to each other, the fast patient turn-over between dialysis sessions, and poor health of the person receiving dialysis.
• The immune system of patients with chronic kidney disease often does not work well, which impairs their ability to fight infection.
• Some of the medicines may also affect the immune system, which can increase the risk of getting an infection.
• Frequent admissions to a hospital may also expose patients to infections such as central line-associated bloodstream infections (CLABSI), methicillin-resistant Staphylococcus aureus (MRSA), and catheter-associated urinary tract infections (CAUTI).

What patients can do:

• Clean your fistula site with soap and water before every dialysis treatment.
• Clean your hands with  soap and water or waterless alcohol-based sanitizer before you start your dialysis session and after you leave.
• If you have a catheter, wear a mask while the nurse is hooking you up to the dialysis machine to prevent germs from your mouth from falling or spraying onto the catheter.
• If you don’t have a permanent fistula, but will need dialysis for your lifetime, discuss the early placement of a fistula with your doctor, before the need for dialysis.
• Get the flu vaccine every year.
• Get the hepatitis B vaccine.
• If you will receive intravenous fluids, request that they do not use the bag for other patients or set up the intravenous tubing until they are ready to administer fluid to you.
• Notify a nurse or doctor if the area around the central line is painful or inflamed, secreting (pus), or if the bandage becomes wet or unclean.
• Seek medical attention immediately if you develop symptoms such as fever, uncommon fatigue, loss of appetite, nausea, vomiting, and/or changes in mental activity. Sometimes patients on dialysis do not develop a fever when they have an infection, so all symptoms are important.

What patients can ask:

• Ask for a hepatitis C blood test before starting dialysis treatment, and then on a routine basis.
• Before receiving an injection, ask if the needle and syringe have been newly opened for you since syringes and needles must be used one time only.
• Ask doctors and nurses to explain why a central line is required, how long you will need to have it in, and if you can use a fistula or graft for dialysis treatment.
• Ask if the dialysis staff put a new external (transducer) filter on the dialysis machine for every patient and replace the filter when it is soaked with blood. This prevents blood from contaminating the inside of the dialysis machine and prevents patient exposure to contaminants.
• Ask if the water used for dialysis is routinely tested for bacteria and if there is a policy in case levels are higher than acceptable.
• Ask if your dialysis caregiver has received the flu vaccine this year.

What patients should observe:

• Check to see if dialysis staff have cleaned their hands before and after they touch you or your dialysis machine.
• Make sure your nurse wears a mask during the initiation and discontinuation of the treatment with a catheter.
• Observe if the dialysis staff cleans the skin of your fistula well with an antiseptic before hooking you up to the dialysis machine.
• Observe if the chair, table, and machine are cleaned between each patient use.

What family members or other visitors can do:

• Wash hands or use an alcohol-based hand sanitizer before and after touching you.
• Wear gloves and a clean cover gown to prevent contamination of clothing.
• Keep wounds covered with a bandage.
• Avoid sharing personal items and clothing.

Dialysis unit Infection control may be divided into three major areas:

• Prevention of transmission of blood borne pathogens (HIV, Hepatitis B and C) from patient to patient, and patient to staff or vice versa.
• Prevention of spread of microbial infection among patients, especially those with the central venous catheter as vascular access.
• Maintenance of water quality within microbiological standards laid down by the Association for the Advancement of Medical Instrumentation 

Control measures for the prevention of transmission of blood borne pathogens:

• All categories of health care workers must be educated on the precautions to prevent transmission of hepatitis B, C and HIV.
• Strict supervision of all work areas is essential.
• It is mandatory to test all patients for HBs Ag, HCV antibody and HIV antibody before hemodialysis, except in emergency situations.
• Separate area for positive patients.
• Disposable gloves, gowns or aprons should be used when caring for patients.
• Mask is to be worn while handling CVC as per protocols.
• Gloves must be used while taking blood or handling.
• Potentially infectious body fluids.
• Blood and other specimens from patients infected with a blood-borne pathogen should be transported the various laboratories for testing in bio-hazard plastic cover.
• Transducer protectors should be used to prevent blood contamination of venous and arterial pressure monitors.
• Terminal Disinfection with Ecoshield following HD of positive patients.
• Rinse is recommended between treatments.
• Disinfection of machine surfaces between dialysis using wet task. (ethanol,1-propanalol,2-propanalol).
• Disinfecting the dialysis machine with chemicals (Citrosteril which contains citric acid-1- hydrate,lactic acid, malic acid)

Prevention of spread of microbial infection between patients:

Prevention of spread of microbial infection between patients especially with central venous catheter as vascular access Catheter-related bloodstream infections are of great concern & hence the following practices are recommended:

• Use aseptic techniques, use sterile gloves and mask when handling catheter
• Instruct not to wet the region
• Occlusive dressing with Tegaderm
• Hemodialysis catheters should be avoided in favor of arterio venous fistulas and grafts; if temporary access is needed for dialysis, a cuffed catheter is preferable to a non cuffed catheter.

• Non tunneled, non-cuffed double  lumen catheters are temporary.

• Tunneled, cuffed double lumen  catheters- long term.

• CDC Guidelines for catheter removal:

        Non cuffed catheter:

        

        Femoral Venous Catheter 2-7days

       Jugular VC – within 21 days

       Tunneled cuffed catheter:

        Till any major infection occur, not responding to  therapy.

Guidelines to be followed during catheter insertion:

• Skin Preparation, cleansing the site with betadine scrub [7.5%]
• Use of an aseptic technique and an antiseptic cleaning solution at the time of insertion.
• Maximum sterile barrier precautions, including cap, mask, gown, gloves, and drape

Handling of catheter during dialysis:

• Hand Hygiene
• Preparation of catheter sites with 2% aqueous chlorhexidine gluconate reduced bloodstream infection rates compared with the use of povidone iodine or 70% alcohol.
• Do not manipulate the CVC

Handling of catheter during dialysis:

Catheter Handling:

Lumens covered with a cap or syringe:

Minimum touch technique:

Use an antiseptic ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session.

CDC Recommendations: 

Use of alcohol-based chlorhexidine (>0.5%) solution as the first line skin antiseptic for catheter exit site care. Apply povidone-iodine ointment or bacitracin/gramicidin/polymyxin B ointment during catheter dressing change. 

Maintenance of Water Quality:

During each dialysis session, the patient is exposed indirectly to 120 litres of water. Therefore, the clinical and microbiological quality of water used for hemodialysis should be within acceptable standards.

The use of water filters, softeners and reverse osmosis (RO) are necessary to ensure chemical purity if the distribution delivery system is made of inert material (e.g.. Stainless steel, or synthetic material).

The AAMI microbiological and endotoxin standards for Dialysis fluids:

Factors that potentiate microbial contamination of water:

• Stagnation in the delivery system,
• The presence of loops and bends,
• Use of bicarbonate concentrate (a good nutrient medium)
• Warming of the dialysate to 37 °C

Environment control:

• Routine cleaning of the unit- 7% Lysol
• Monthly cleaning of fan and tube light
• Weekly thorough cleaning of unit, trolleys, cots – 7% Lysol
• Linen -1% Dakins [positive cases]
• Air conditioners   with 10% Ecoshield
• Monthly microbiology surveillance
• Cleaning and fogging of OR with Ecoshield before any invasive procedure.
• Disinfection of RO water tank, bicarbonate mixing tank weekly with 37% formaldehyde.
• Water testing for endotoxin levels (<0.25 EU).

Fogging in Dialysis Unit:

• Weekly Schedule Need to Be Prepare for whole month.
• Either weekly or before tunneled cuffed catheter CAPD catheter insertion and after taking a positive patient.
• Fogging the zones with 20%ecoshield (stabilized hydrogen peroxide 11% w/v with 0.01% w/v of silver nitrate).

Written by:

Dr. Praveen Bajpai

Director of Ingenious Healthcare Consultants Pvt. Ltd.
Founder of Skill Sathi

MBA in Hospital administration, PG Diploma in Quality Accreditation, PG Diploma in Medico Legal System, M. Phil in Hospital Mgmt. from BITS Pilani, P.hD in Management, Certified NABH Auditor, Certified NABL Auditor, Certified Auditor for Clinical Audits, Green Belt in Six Sigma, Certified in Hospital Infection Control Practices, Certified trainer for International Patient Safety Goals, Certified Auditor for JCI 7th Edition Standards 

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